Application for Insurance Agent Certificate of Authority

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Personal information on this application form is collected under Sections 345, 346, and 347 of the Insurance Act, as it relates directly to and is necessary for the purposes of applying for a certificate of authority to act as an insurance agent. If you have any questions about this collection of personal information, you may contact the Superintendent of Insurance, Financial and Consumer Services Division, 902-368-4550.

Identification

First Name

Middle Initial

Last Name

Address 1

Address 2

City, Town, or Community

Province

Postal Code

For example C1B 0X1 or 12345

Country

Telephone Number

For example 902-555-5555

Email Address

Business Information

Are you employed by an insurance agency?

Legal Name of Insurance Agency (e.g. ABC Insurance Agency Inc.)

Does the agency operate under a trade name or “doing business as” name?

List all applicable full legal trade names

Click the Add button below to add more.

List all applicable full legal trade names
	Agency's Full Legal Trade Name	Item weight

more items

Is this corporate agency registered in the PEI Corporate Registry?

All businesses and corporations operating in PEI are required to be registered in the PEI Corporate Registry. Visit PEI Business Corporate Registry if you are unsure.